Provider Demographics
NPI:1497424394
Name:ALLEN, JENNIFER LYNN
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:ALLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:KOEPKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6440 N SUNSET LN
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-4141
Mailing Address - Country:US
Mailing Address - Phone:608-290-4653
Mailing Address - Fax:
Practice Address - Street 1:13111 N PORT WASHINGTON RD RM 121
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53097-2416
Practice Address - Country:US
Practice Address - Phone:262-243-8453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-13
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2266330163W00000X
WI1126633363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse